Our care is generally good in the United States but not as good as it could be nor as good as it should be. There are multiple problems to consider.
First, ours is a medical care system not a health care system. We focus on disease once it has occurred but give relatively little attention to maintaining health and developing wellness.
Clearly there is a need for greater attention to disease prevention and health promotion. Second, our sytem developed over many decades to care for acute illness but today we are faced with more and more chronic diseases. Sure there are still patients with an ear infection or a broken leg. But more and more individuals are developing diabetes, heart failure (both of these now becoming epidemics), cancer, chronic lung disease and others. These are illnesses that generally last a lifetime (some cancers can be cured, of course), are complex to manage and inherently expensive to treat. They are best handled by a multi-disciplinary team coordinated by a primary care physician. But such is seldom the case today.
Third, of course, many do not have health insurance with some 47 million uninsured and many more underinsured. And as they obtain insurance or join the Medicaid ranks as the result of healthcare reform, there will be way too few primary care physicians to care for them. They will therefore continue to use the emergency room as their principle place for care.
Fourth, our system of care is not customer-focused. We wait long weeks and months for an appointment, spend long times in the waiting room and are frustrated that we get just 12-15 minutes with our doctor. Our doctor suggests that we go to a specialist but does not personally call the specialist to explain the issue nor to smooth the path for a speedy appointment.
And then there are the insurers. We are not their customer – our employer is their customer or our government is their customer but not us. And it shows – by our long waits on the phone, by the complex often hard to understand paperwork and by the frustration when the insurance we thought we had does not cover our latest tests, x-rays or specialist visit.
Indeed we are not the insurer’s customer nor are we the doctor’s customer. The physician is the customer – sort of – of the insurance company. We are mere bystanders. This is hardly the type of contractual relationship we have with our lawyer, architect or accountant.
So a new vision for our system must make it a healthcare not just a medical care system. It must recognize the importance of intensive preventive care to maintain wellness. It must address the needs of those with chronic illnesses (who consume 70-85% of all healthcare claims paid) to both improve quality of care while dramatically reducing the costs of care. And it must be redesigned so that the patient is the customer that he or she should be – of both the physician and the insurer. It’s doable but it means a rethinking of how our delivery system is structured.
One thing individuals can do now is to obtain a high deductible insurance policy. This means your premiums will come down and you will be paying for primary care out of pocket. But primary care is generally not expensive and now you will be in a position to expect more from your doctor – after all, it is you who is paying the bill and doing so directly. Alternatively, look for a PCP that has a retainer based practice or simply does not accept insurance. In each of these scenarios, you now have a direct professional contractual relationship with your doctor. You will be treated as such and now you are more likely to challenge suggestions and ask questions. You will also get better preventive care because the doctor has more time to spend with you. The result will be far fewer referrals to specialists, fewer tests and procedures and an ultimate savings in health care costs.